Back Pain

In November 2007, I had a longish article in Best Life Magazine on the psychology of chronic back pain. Apparently, the version of the article on the Best Life website no longer works, and I regularly get emails from people asking to read the actual text. So in order to establish a future reference and permanent link, I'm going to post all 5000 words below the fold:

A growing cadre of doctors and scientists now believes that chronic back pain is a disease of the nervous system, not the spine. This breakthrough has opened the doors to new kinds of treatments that could banish back pain forever.

Dr. Marc Sopher, a family physician in Exeter, New Hampshire, is drenched in sweat. He's just run eight miles on a humid summer morning and played a game of tennis. (He's going for a bike ride later, after he sees his patients.) His short hair is salted with white - Sopher is 46 - but he has the taut body of a young athlete. Whenever he moves, you can see his muscles flex and twitch. He shakes my hand, ushers me into his office, and then excuses himself to take a shower.

When Dr. Sopher returns, he begins telling me the story of his back pain. "It began in my early thirties," he says. "I couldn't even sit down. I would get this throb in my lower back and then a sharp pain down one leg or the other. I was really in a pretty bad state." At first, Sopher tried to ignore the pain. He assumed that he had aggravated something in his back and waited for the aggravation to subside. "I'm a traditionally trained physician," he says, "so I started taking some anti-inflammatories, and then, when the pain wouldn't go away, I just tried to endure it. I honestly believed that I wouldn't be able to sit down again for the rest of my life."

Sopher no longer has back pain, but he wasn't healed by conventional medicine. He didn't undergo surgery, or get epidural injections, or take painkillers. Physical therapy didn't help. Instead, Sopher is one of the thousands of patients suffering from chronic back pain who got better by treating their mind. He learned to think differently about his pain, and that's when his pain went away. This narrative might sound suspicious - there's no shortage of phony treatments for chronic back pain - but it's supported by a growing body of scientific evidence. Chronic back pain is now predominately seen as a disease of the nervous system, not the spine; it's a problem suited for psychologists and neuroscientists, not surgeons. The best treatments are often the least invasive.

For Sopher, the road to recovery began with a book. It was Healing Back Pain, by Dr. John Sarno, a physician at NYU. "Once I started reading this book," Sopher says, "I couldn't stop. It was like a revelation. As the hours go by, I become aware that I've been sitting for a long period of time without any pain." While nothing had changed in Sopher's back - it was still a mess of herniated discs - he was learning how to think about his pain in a new way. "That's when I reminded myself that I'm a serious doctor, and that just reading a book isn't supposed to cure pain. But my pain was gone. That's when I decided to contact Dr. Sarno. I needed to learn how this is done."

The Rusk Institute of Rehabilitation Medicine lies on the eastern edge of Manhattan. It's a squat brick building overlooking the highway. Watching patients enter the Institute is a sobering experience. The full variety of human limps is on display. People hobble through the doors wearing cervical collars and shoulder slings and elaborate knee braces. They lean on canes and crutches. It's like a parade of pain.

Dr. John Sarno's office is hidden away on the ground floor. He keeps his door locked, even during office hours. When I first enter Sarno's waiting room, I wonder if I've mistakenly wandered into the closet. The room is musty, windowless and full of stacked cardboard boxes. A few crooked impressionist posters line the walls. There are no glossy magazines.

Sarno is eighty-five years old - he's been practicing medicine since 1950 - but he still sees new patients three days a week. He talks slowly, with the pedantic patience of someone used to explaining his ideas.

"When I first started treating patients with back pain," Sarno says, "I practiced conventional medicine. I relied on all the usual tools, like injections and strengthening exercises. As the years passed, I grew very frustrated because I realized that all the conventional treatments were utterly useless. My patients weren't getting better. In fact, I was probably making them worse."

Sarno's failure caused him to question a fundamental assumption of modern medicine. In general, doctors assume that bodily pain is a response to bodily injury. Our back hurts because a disc is herniated or a nerve is pinched or a muscle is strained. The agony has a structural cause. Fix the structure and the agony goes away.

But Sarno began to doubt this explanation, at least when it came to chronic back pain. "Once I started thinking about it," he says, "the structural diagnosis stopped making sense. It couldn't explain a whole range of issues, like why these chronic pain patients never got better, or why they also suffered from a range of other illnesses." So Sarno started to search for another cause. If nothing was wrong with the body, then where did the pain come from? Why were healthy people hurting? That's when Sarno had his epiphany: chronic back pain was caused by the mind.

This theory, which Sarno has expounded in a series of popular books, has an alluring simplicity. He argues that much of our physical suffering is rooted in the machinations of the unconscious brain. Sometimes, when we repress our anger, deal with undue amounts of stress, or experience some upsetting emotion, the mind induces bodily pain as a form of distraction. It mischievously turns a minor physical incident - like lifting a heavy object - into a set of debilitating physical symptoms. Our back hurts so that we don't think about our emotional hurt. The suffering, of course, is yet another source of stress, which only makes the suffering worse. The pain becomes a downward spiral.

According to Sarno, the only way to cure chronic back pain is through rigorous psychological treatment, which seems to consist mainly of believing in Sarno's theories. Patients need to continually remind themselves that the pain, though real, is rooted in their own mind. (Sarno recommends that his patients read his lecture notes at least once a day.) Unless the patient unconditionally accepts Sarno's diagnosis, he or she won't get better. It is the faith that sets them free.

There is little scientific evidence for Sarno's theories. He hasn't published a medical paper in years. Sarno's notions of the unconscious mind are largely derived from Freud, and Freud isn't exactly cutting-edge science. One back pain specialist told me that, while he was sympathetic to Sarno's "psychological theme," he was troubled by his "penchant for constructing theories without the necessary foundation of facts." But the criticism doesn't concern Sarno. He's convinced that he's discovered something important about chronic back pain. As Sarno puts it, "My proof is that my patients get better. That's the only proof I need."

Sarno's clinical success shouldn't be dismissed as just another instance of the placebo effect. While there have been no independent studies of Dr. Sarno's success rate, the anecdotal evidence is certainly suggestive. Entering one of the numerous forums dedicated to Sarno on the Internet is like wandering into a Pentecostal revival meeting. New testimonials appear everyday, with people confessing that years of chronic pain ended as soon as they read one of Sarno's books. They tell stories of expensive surgeries that didn't help, and scary spinal diagnoses that couldn't be treated. And then, after years of suffering, they talk about how they stumbled upon Sarno, and how they were saved. (Howard Stern is a particularly devoted fan. He dedicated his memoir to Sarno, and frequently mentions Sarno's approach to back pain on his satellite radio show.)

In a 1999 investigative report on ABC News, reporter John Stossel randomly selected twenty of Sarno's former patients from his medical files. After tracking these people down, Stossel found that all twenty reported being "better or much better." Stossel himself was treated by Sarno after suffering for years from recurring bouts of lower back pain. "It's so embarrassing," Stossel said, "but after one lecture, Sarno cured me." Although his back still acts up, Stossel has learned to ignore the pain. "Instead of fixating on the pain, I just wait for it to go away, try to think about the stress or emotions that may have triggered it, and then the pain goes away," he says.

According to Stossel, he has gotten more positive comments about his Sarno report than anything else he's ever done. "All these years later, I still get people coming up to me on the street saying that they saw my piece on Sarno, and that it changed their life."

America is in the midst of a back pain epidemic. The numbers are sobering: there's a 70 percent chance that, at some point in your life, you'll suffer from severe back pain. There's a 30 percent chance that you've suffered from severe pain in the last thirty days. At any given time, about 1 percent of working age Americans are completely incapacitated by their "lower lumbar regions". Treating this chronic back pain is expensive (more than twenty-six billion dollars a year), and currently accounts for 2.5 percent of total health care spending. If worker compensation and disability payments are taken into account, the costs are far higher. "Unless you believe that something catastrophic has happened to the backs of Americans in the last few decades," Sarno says, "this epidemic is hard to explain."

The conventional medical treatment for back pain follows a predictable script. After the patient is interviewed and given a physical exam, he or she undergoes a series of diagnostic tests. This normally includes X-rays, CT-scans and MRI imaging. The end result is an astonishing array of detailed anatomical pictures. Doctors no longer need to imagine the layers of tissue underneath the skin. Now they can see everything.

Unfortunately, all this seeing has limited results. After undergoing the full range of diagnostic tests, 85 percent of patients suffering from lower back pain still don't receive a precise diagnosis. The pain can't be pinpointed; there are just too many moving parts. Instead, their suffering is parceled into a vague category, like a "lumbar strain" or "spinal instability".

But even when a patient is given a specific structural diagnosis, it's not clear how meaningful the diagnosis actually is. Look, for example, at herniated discs, one of the most common "causes" of back pain. A 1994 study published in The New England Journal of Medicine imaged the spinal regions of ninety-eight people with no back pain or any back related problems. The pictures were then sent to doctors who didn't know that the patients weren't in pain. The end result was disturbing: two-thirds of the pain-free patients exhibited "serious problems" like bulging, protruding or herniated discs. In 38 percent of patients, the MRI revealed multiple damaged discs.

The disconnect between "disc degeneration" and back pain increases with age: more than 80 percent of people over the age of 60 who don't have any back pain still demonstrate "significant disc degeneration". These structural spinal abnormalities are often used to justify expensive treatments like surgery, and yet nobody would advocate surgery for people without pain. In the latest clinical guidelines issued by the American College of Physicians and the American Pain Society, doctors were "strongly recommended...not to obtain imaging or other diagnostic tests in patients with nonspecific low back pain." In too many cases, the expensive tests proved worse than useless.

Despite these flawed diagnostic tests, about 90 percent of patients suffering from back pain get better within seven weeks. The body heals itself, the inflammation subsides, the nerve relaxes. These patients go back to work and pledge to avoid the sort of physical triggers that caused the pain in the first place.

But the remaining ten percent of patients don't get better. For these desperate people, there are no good medical options. The longer their pain persists, the less likely they are to ever recover. Chronic pain is the pain that won't go away.

From the perspective of the brain, there are two distinct types of pain. The first type of pain is sensory. When we stub our toe, pain receptors in the foot instantly react to the injury, and send an angry message to the somatosensory cortex, the part of the brain that deals with the body. This is the type of acute pain that doctors are trained to treat. The hurt has a clear bodily cause: if you inject an anesthetic (like novocaine) into the stubbed toe, the pain will quickly disappear.

The second pain pathway is a much more recent scientific discovery. It runs parallel to the sensory pathway, but isn't necessarily rooted in signals from the body. The breakthrough came when neurologists discovered a group of people who, after a brain injury, were no longer bothered by pain. They still felt the pain, and could accurately describe its location and intensity, but didn't seem to mind it at all. The agony wasn't agonizing.

This strange condition - it's known as pain asymbolia - results from damage to a specific subset of brain areas, like the amygdala, insula and anterior cingulate cortex, that are involved in the processing of emotions. As a result, these people are missing the negative feelings that normally accompany our painful sensations. Their muted response to bodily injury demonstrates that it is our feelings about painâ¯and not the pain sensation itselfâ¯that make the experience of pain so awful. Take away the emotion and a stubbed toe isn't so bad.

Chronic pain is the opposite of pain asymbolia. It's what happens when our brain can't stop generating the negative emotions associated with painful sensations. These emotions can persist even in the absence of a painful stimulus, so that we feel an injury that isn't there. It's like having a permanently stubbed toe.

Doctors have traditionally focused on the bodily aspects of chronic pain. They assume that a healed body is a painless body. If a patient has chronic back pain, for example, then he is typically prescribed painkillers and surgery, so that the pain signals coming from his spinal nerves are stopped. But the dual pathways of pain mean that this approach only treats half of the pain equation. Unless you find a way to treat the emotional pathway, then the chronic pain will continue.

"The standard model of painâ¯the same model that is still taught in every medical schoolâ¯is that you treat the pain by fixing the underlying pathology," says Dr. Sean Mackey, a Professor at Stanford and Associate Director of the Pain Management Division. But the reality of pain, Mackey says, is much more complicated. "We're now beginning to recognize that you can't talk about chronic pain without talking about its psychological aspects. It's a condition in which signals from the body are literally distorted by the brain."

Mackey is at the forefront of a new paradigm in pain research. In many respects, he is an unlikely revolutionary. "My Ph.D was in electrical engineering," Mackey says. "Nobody was more mechanistic than I was. When I began treating patients, I was very interested in trying to identify the structural source of the pain. I'd do lots of injections, stuff like that. But what I found, much to my surprise, was that my patients were getting better more from my talking than from any medical procedure. I was intrigued by that, and so I started to look into the mechanisms of why talking to my patients might reduce the pain. That's what led me to study the brain, and not just the body."

Mackey's personal experience now has strong scientific support. In recent years, it has become clear that one of the most powerful ways to treat chronic back painâ¯or any pain, for that matterâ¯is by treating the mind. When patients are taught how to deal more effectively with the negative emotions that accompany chronic pain, they often experience dramatic improvements. The pain that wouldn't disappear is suddenly diminished. Psychological interventions can heal the hurt.

Robert Kerns has been studying the psychology of pain for thirty years. He's a Professor of Psychiatry at Yale University, and the National Program Director for Pain Management at the Veterans Health Administration. When Kerns was in graduate school, back in the late 1970's, he happened to treat a patient with terrible back pain as a result of kidney disease. Even though this patient had a serious physical condition, Kerns noticed that psychological therapy helped her cope with the pain.

"That's when I began to appreciate that a person's thinking could really affect their pain experience," he says. "Our chronic pain isn't beyond our control."
At the time, there was little hard evidence to support such mental interventions. Treating chronic pain with psychological therapy was like treating cancer with a poem: the best thing most doctors could say about it was that it would do no harm. But few doctors expected it to actually help. Pain, after all, was a medical condition. Therapy was just words.

But the words work. Kerns' most recent study, published in January 2007 in Health Psychology, is also his most definitive. It's a meta-analysis of twenty-two trials that looked at the effectiveness of psychological treatments for patients with chronic lower back pain. The statistics were complicated, but the results were clear: psychological treatments made the pain go away. Patients with chronic back pain could reduce their suffering by learning how to think differently about their pain. Benson Hoffman, a clinical associate at Duke University and co-author on the study, was surprised by the robustness of the data. "Going into the study," Hoffman says, "I thought that psychological interventions would probably increase a patient's quality of life, but not actually reduce their pain. But my hypothesis was wrong. These psychological treatments reduced the pain more than anything else."

Think, for a moment, about what this means: these patients didn't do anything to treat their bodily symptoms. And yet, after just a few treatment sessions, their pain started to subside. According to the meta-analysis, the two most effective psychological interventions were cognitive behavioral therapy and "self-regulatory therapies," like biofeedback. Cognitive behavioral therapy is a popular form of talk therapy that teaches patients how to adopt a problem-solving approach to their pain.

The simple premise of the treatment is that we are capable of controlling our own thoughts, emotions and experiences. Therapists teach patients specific mental exercisesâ¯such as keeping a journal, or practicing relaxation techniquesâ¯that help them manage their negative feelings and alleviate their suffering. The goal of the therapy is to re-train the brain, so that the cycle of pain is stopped. Self-regulatory therapies, on the other hand, show people how to take back control of their body. By giving patients information about their own internal processesâ¯such as readouts of their blood pressure and brain wavesâ¯the therapy teaches them how to modulate these processes. The mind needn't be a slave to the flesh.

"Many patients with chronic back pain develop a deep sense of hopelessness," Kerns says. "These therapies show them that they can develop everday strategies that make them feel better. I think one of the things that modern medicine has forgotten is that it's important to treat the whole person, and this means addressing both the physical and psychological aspects of the pain. When it comes to back pain, just fixing a 'broken' body part often isn't enough."

One of the first studies to demonstrate the importance of psychological factors for back pain came from an investigation of 3,000 employees at Boeing in the 1980's. Over a four year period, nearly ten percent of these employees developed chronic back pain. When doctors analyzed the factors that predicted the onset of this pain, they were surprised to learn that structural back problems played a negligible role. Factory workers who constantly lifted heavy objects were no more likely to experience disabling pain than office workers. Instead, the best predictor of chronic pain was emotional distress. Employees who were suffering from depression, stress, or just disliked their boss, were much more likely to suffer from debilitating back pain.

A study recently published in Spine made a similar point. Dr. Eugene Carragee, a professor of orthopaedic surgery at Stanford, was the lead author. He tracked nearly 100 patients over several years, attempting to better understand the specific structural ailments that cause chronic back pain. The researchers imaged people in MRI machines and used discographies to pinpoint the structural source of the discomfort. They also put the patients through regular psychological evaluations.

Carragee's results, like earlier studies, demonstrated that neither discographies nor MRI's were reliable predictors of chronic back pain. While two-thirds of patients with chronic pain had small cracks in their discs, so did 24 percent of patients with no pain at all. "The real issue," says Carragee, "is, why do some people have a mild backache and some have really crippling pain?"

To answer this question, Carragee analyzed the psychological evaluations of his patients. He soon discovered that a person's emotional stateâ¯and not the anatomical state of their backâ¯was the best predictor of back pain. As Carragee notes, "The structural problems were really overwhelmed by the psychosocial factors. Almost without exception, people without any of these mental risk factors were able to accommodate to the back pain. They were able to deal with their back ache. But people with a psychological problem had a much tougher time doing that. For them, the pain was often crippling and catastrophic."

While scientists have yet to find the specific mechanisms that connect our psychological problems to chronic pain, there are beginning to uncover some tantalizing clues. One possibility is that mental disorders make people more vulnerable by weakening the specific brain regions and neurotransmitter systems that are also involved in the perception of chronic pain. For example, a brain-imaging study published last August by researchers at the University of Wisconsin found that people with clinical depression were much less able to regulate their negative emotions than a control group. According to Tom Johnstone, a neuroscientist who led the research, when depressed individuals tried to turn off their own emotions, these attempts ended up backfiring. "The more effort they put in," he says, "the more activation there was [in the emotional areas of the brain]." As a result, bad feelings tended to spiral out of control.

A similar process might be at work in chronic pain. According to this hypothesis, the pain persists in the emotional areas of the brain because patients are literally unable to turn it off. Whenever they think about the pain, they just make it worse. (The Wisconsin researchers speculate that depressed individuals might have a "broken link" in the brain, which makes the regulation of negative emotion impossible.) What makes this research valuable is that it opens up new possibilities for the treatment of chronic pain. In recent years, for example, doctors have found that anti-depressants, especially tricyclics, are often effective treatments for chronic back pain. These drugs help control the emotions that the patients cannot.

Chronic stress is another important risk factor for chronic pain. One back surgeon, who wished to remain anonymous for fear of offending his patients, said that he's seen several men develop lower back pain shortly after getting engaged. "Weddings are stressors," he says, "and that stress can exacerbate the experience of pain." Intriguing clues are beginning to emerge about how, exactly, stress might modulate pain. Joyce Deleo, a neuroscientist at Dartmouth, has discovered that chronic pain is often triggered by a response from the immune system. When Deleo bred mice that were missing a specific type of immune receptor, the mice proved much less vulnerable to the lingering effects of pain. Of course, it's long been recognized that bouts of stress can profoundly alter the nature of our immune response. "I think the medical community is finally beginning to understand just how complicated the phenomenon of chronic pain is," Carragee says. "There are so many different psychological variables that can amplify and distort our experience of pain. You can't just wield a scalpel and make it go away."

The moral of these studies is clear. Modern medicine has been trying to fix chronic back pain by fixing the back. We spend tens of billion dollars every year imaging our degenerated discs, fusing our vertebrae, popping painkillers and engaging in a vast array of injections, massages and physical therapies. But for many people suffering from chronic back pain, these medical interventions won't work. Their doctors have been looking in the wrong place. The best way to treat chronic pain is to treat the brain.

Imagine you are a doctor, and a patient comes into your office with a serious case of back pain. Instead of doing the usual physical exam and patient interview, you decide to just study his mind. You don't even look at his back. It turns out that, by simply paying attention to a few variables inside his headâ¯the size of certain brain regions, the concentration of certain brain chemicalsâ¯you'll be able to predict about 80 percent of the individual variance associated with chronic back pain. You'll have a rather accurate sense of how intense his pain is and how long he's been suffering from the pain. In contrast, the conventional method of diagnosisâ¯this involves looking at the back and spineâ¯can account for less than 25 percent of the variance of back pain. When it comes to diagnosing chronic back pain, the brain reveals more than the body.

Dr. A. Vania Apkarian is a Professor of Neuroscience at Northwestern. He's been studying the neural underpinnings of chronic pain for more than twenty years. In 2004, he published a paper demonstrating that chronic back pain appears to cause brain damage. For each year of agony, people lose about a cubed centimeter of gray matter. With time, the centimeters add up: Apkarian found that subjects with chronic back pain had anywhere from 5 to 11 percent less gray matter than control subjects. The suffering is literally toxic.

In a 2006 paper published in The Journal of Neuroscience, Apkarian's lab located the specific brain areas triggered by chronic back pain. The scientists found that chronic painâ¯unlike acute painâ¯activated brain regions typically associated with negative emotions, thus providing further evidence that chronic pain is really an emotional disorder. It's a malfunction of the second pain pathway. "It's as if people with chronic pain have internalized the pain," Apkarian says. "It's become part of who they are. That's why you can't just treat the body."

At first glance, this data is dispiriting. The pain of long-time sufferers appears to be literally built into their brain, cemented in the soul. But Apkarian is also working on treatments that might alleviate the suffering at its neural source. In June 2007, Apkarian's lab published a paper in Pain documenting the ability of a pre-existing drug, D-Cycloserine, to end chronic pain in rats. While D-Cycloserine was originally designed to fight tuberculosis infections, it also appears to suppress the emotional component of chronic pain. After thirty days of pharmaceutical treatment, the rats were living pain free lives. Apkarian is hoping to begin a clinical trial with chronic back pain patients later this year. "When we do this in a clinical trial, we expect people to say 'I still have the pain, but it's not bothering me anymore,'" Apkarian says. "We think they will have a physical awareness of the pain, but its emotional consequences will have decreased." The chronic part of chronic pain will have been erased from the brain.

Despite the persuasive body of evidence demonstrating the psychological component of chronic back pain, the vast majority of patients still reject any diagnosis that smacks of psychology. Sarno holds the medical establishment responsible for this state of affairs. "What's going on now is a disgrace," he says. "You have well-meaning doctors making structural diagnoses despite a serious lack of evidence that these abnormalities are really causing the chronic pain. All these incorrect diagnoses actually make it harder for the patients to benefit from psychological treatments. I can't help people until they accept the mind-body aspect of their pain."

Everyone agrees that a big part of the solution is better patient education. "A lot of what I do is educate people about what their MRI's are showing," says Dr. Mackey. "I remind them that the only perfectly healthy spine is the spine of an eighteen year old, and that degeneration is often part of a normal process. Patients have to get beyond their fear of pain, because the fear keeps them from progressing. It's like they slip into a state of learned helplessness."

Many patients also find the possibility of a psychological diagnosis insulting. They assume that, if the pain has a mental component, then it must be make-believe. "When you first tell a patient that their mind might be responsible for the pain, they think you're calling them crazy," Dr. Sopher says. "I always tell that the pain is no less real because it's being caused by the mind. The pain is still real and it's still debilitating. It just means that getting better means changing something in your mind, not your back."

The good news is that, while we can't realign our spines or fix our ruptured discs, we can control our perception of chronic pain. With the proper training, we can alleviate our own suffering. That, at least, is the optimistic conclusion of a recent Stanford study performed by Mackey and other researchers. The study used real time fMRI brain imaging to teach people with chronic pain how to modulate their conscious response to the pain. Some of the subjects distracted themselves with pleasant thoughts, while others recited mantras, or listened to soothing music. Despite the diversity of strategies, each of the patients could see the direct impact of their palliative thoughts. They watched as the specific parts of their brain associated with chronic painâ¯like the anterior cingulate⯠gradually subsided in activity. They had become their own painkiller.

The results of the experiment were dramatic. Every single chronic pain patient reported a decrease in pain intensity, with an average decrease of 64 percent. The patients had stopped being the helpless victims of a structural abnormality in the body, and could now focus on dealing with the pain in their mind. Simply knowing that they could control the pain somehow made the pain less terrible.

Dr. Christopher deCharms, a lead author on the Mackey paper, is trying to take this therapeutic approach mainstream. He's started a company, called Omneuron, that makes the experimental treatment available to a wider audience. A standard treatment session goes like this: a patient lies in a brain scanner while experiencing pain. They watch as their brain flares up in agony. Then, with the help of a trained therapist, the patient learns how to consciously turn off the brain areas that correlate with the chronic pain. It's a perfect example of mind over matter.

The science of back pain has come a long way since Dr. John Sarno, frustrated by his medical failures, decided that the mind played a crucial role in chronic back pain. His unscientific hunches have been replaced by a bevy of new scientific facts. More importantly, this increased understanding has led to an assortment of new treatments. And yet, the single biggest obstacle to treating chronic back pain remains our old beliefs. Until we accept the psychological component of chronic pain, the pain won't go away. It will just linger on, not in our backs, but in our mind.


More like this

I've got a new article on the psychology of back pain in the February issue of Best Life (the one with Jeff Gordon on the cover): I've put the entire article below the fold: Dr. Marc Sopher, a family physician in Exeter, New Hampshire, is drenched in sweat. He's just run eight miles on a humid…
Over at the wonderful World's Fair, Ben Cohen has an interview with Kelly Joyce, author of the forthcoming Magnetic Appeal: MRI and the Myth of Transparency. Here is how Joyce summarizes the main argument of her book: In the United States, MRI is socially constructed as a sacred technology--one…
Over at Mind Matters, Chadrick Lane reviews a fascinating experiment that revealed the rewarding properties of information, regardless of whether or not the information actually led to more rewards: In the experimental design, monkeys were placed in front of a computer screen and were trained to…
One of the case studies I use in How We Decide when discussing the dangers of information overload concerns the diagnosis of back pain. Before the introduction of MRI's in the late 1980s, doctors were forced to rely on X-rays when diagnosing back pain. X-rays provide doctors with a limited amount…

Most interesting. However, it's marred by what seems to me to be a persistent air of overstatement.

Examples -

I realized that all the conventional treatments were utterly useless. (Sarno)

This is of course demonstrable nonsense. "Only work for some"? "Don't work well for many"? OK, but "utterly useless"? That sounds like fanaticism and anti-science silliness to me.

The good news is that, while we can't realign our spines or fix our ruptured discs, we can control our perception of chronic pain.

This seems to me to ignore the reality that some back problems if left untreated will do irreparable physical harm. And of course to say "we can't realign our spines or fix our ruptured discs" is also demonstrable nonsense.

The attitude of the article seems to be that pain is bad, and that's an extreme and unsupportable approach. Take an extreme example - if I can be trained to ignore the pain of putting my hand on a hot stove burner, would that be a good thing?

There's lots of fascinating and potentially useful stuff here, but it seems to me to be just about as unbalanced as the myth that "all a back doctor will want to do is cut you open."

By Scott Belyea (not verified) on 09 Jan 2009 #permalink

Thank you for publishing this on line. My own experience has been that reducing my stress level, being more active, losing a little weight, taking some supplements, etc. has made a big difference in my ability to tolerate or ignore the back pain I've had for some 15 years. I did have surgery eight years ago, and I think it helped in my eventual recovery, but that effect could have been psychological, too. Who knows. The brain is a strange and interesting world.

As a semi retired orthopedic surgeon with a great interest in spine disorders I have regularly asked patients to read Hamilton Hall's texts, updated regularly, on back pain and have had the residents in training review the essay by Jerome Groopman, "a stab in the bacK", firt published in the new yorker and republished in his text and on his blog. He discusses his treatment through surgeries and then exercise.
The mechanical, biochemical causes of back pain are many. Some respond to surgery, although surgery is most useful for definable compression of nerve or spinal cord and gross mechanical instability. Most of us who do or have done spine surgery for back pain have followed the holy grail of techniques to stop it with variable and often unpredictable outcomes. I describe the passion to define mechanical cures in our being captured in a Cartesian universe, whereas pain is often centralised.

By richard scott (not verified) on 12 Jan 2009 #permalink

I've just returned from a 10 day meditation seminar put on by During this seminar, I was taught a technique of meditation (vipassana) that is said to have been orignated by Gautama Buddha 25 centuries ago. During the many hours of stationary meditation, my body went through incredible discomfort, or pain if you will. Back pain, knee pain, muscular pain, skin pain, numbness, in short all varieties of pain, intense and not so intense, from I think I'm going to die pain, to that's interesting pain. What I learned, was to observe the emotions associated with the pain, and learn to separate my experience of the emotions from my experience of the sensory input. Once I learned to separate emotion from sensation, the pain became first tolerable, then would disappear completely. I was able to directly observe how my emotions could amplify a simple discomfort a thousand fold. Human cognition is an incredible thing. I would recommend this meditation course for any professional working in the field of pain management.

I think this article is very interesting. The concept of "mind over matter" is very disturbing to me, because it implies that one learns to ignore pain that is indicating that something is wrong. However, EFT teaches to challenge pain, and find out if SOME of it might be due to an emotional cause. Pain usually indicates that the sufferer believes that something is wrong. Sometimes something is very wrong. Sometimes nothing is wrong, except one's beliefs. By challenging any underlying beliefs and associations to the pain, often a resolution of the pain or a direct course of treatment for any physical causes of the pain can result.
Usually the emotional or beliefs component is far stronger than the mechanical problem component.
In addition, often the emotional component creates RESISTANCE to understanding and fixing the mechanical component. This very resistance often manifests as pain. In addition, the emotional reason may be causing the person to be in a situation where he is likely to be injured. Thus it doesn't make sense to treat injuries and pain in isolation.

An injury or difficult situation, when one has a clear and confident course of action, is much less painful than a situation in which one is conflicted. Hence, gaining a deeper understanding of the ways that one is conflicted, and the opposite - seeing the possibilities available, is a beautiful way out of the pain paradigm.
As mentioned in the article, chronic pain is in a different category from acute pain. According to the mechanical structure default=pain theory, if one has chronic pain, this means one has something very wrong going on inside them. However, this might not reflect reality. It can perhaps even create reality, because if one assumes for an extended period of time that one is as damaged as one's pain indicates, then one may go on to think all sorts of unpleasant things about oneself. In this way the pain and tendency to injury can spiral out of control.
Dr Sarno seems to say "don't believe in mechanical problems causing the pain - believe me instead". I would like to read more about his method, but I don't like that it seems to ask people to implicitly trust someone else. This does not seem to be very honoring, (to the sufferer) nor does it help the individual to learn anything about the terrain of his brain.
I think it would be more liberating to help people learn more about what is causing their own pain, since these are probably matters that are very important to him.

By Rachel G. (not verified) on 13 Jan 2009 #permalink

Back pain treatment statistics are so ineffective due to the gross neglect of medical providers to acknowledge the obvious and proven interactions between mind and body. How can therapy options cure back pain when they are directed at a mistakenly identified anatomical source? So called spinal abnormalities have been debunked as the causes of most back pain. This is a wake up call to all chronic pain specialists; and a long overdue wake up call at that! God bless Dr. Sarno and all the other fine physicians practicing true mind/body medicine.

The lack of mainstream acceptance for Dr. Sarno's theories is one of the biggest problems in medical training today. The spectrum of diseases for which the patient's psychological/emotional profile play a significant role in their etiology is vast and far from limited to just back pain. That being said, a psychological approach to chronic back pain is the only legitimate avenue for treating such patients.

The value of the enormous advances in modern science over the last half-century cannot be overstated. We now have the ability to cure certain types of cancers, infections, etc. However, with this increase in technological capability has come a neglect for one of the most important aspects of patient care: the role of psychomatic medicine.

I am hopeful that continued advances in neuroscience will bring us full circle to the point where we can again effectively treat the mind and body as the inseparable entity that it is.

By Michael Kadoch (not verified) on 24 Jan 2009 #permalink

The lack of mainstream acceptance for Dr. Sarno's theories is one of the biggest problems in medical training today. The spectrum of diseases for which the patient's psychological/emotional profile play a significant role in their etiology is vast and far from limited to just back pain. That being said, a psychological approach to chronic back pain is the only legitimate avenue for treating such patients.

The value of the enormous advances in modern science over the last half-century cannot be overstated. We now have the ability to cure certain types of cancers, infections, etc. However, with this increase in technological capability has come a neglect for one of the most important aspects of patient care: the role of psychosomatic medicine.

I am hopeful that continued advances in neuroscience will bring us full circle to the point where we can again effectively treat the mind and body as the inseparable entity that it is.

By Michael Kadoch (not verified) on 24 Jan 2009 #permalink

I am a therapist who specializes in treating chronic pain patients on opiates who also have addiction issues. Cognitive Behavioral Therapy is a technique i use with my patients. We work on understanding the gate theory of pain which is very similar to the theory proposed here. As someone who also has pain issues, I believe that understanding the role our thoughts play in how we handle pain is crucial if a person is to have effective pain management. Hopefully more health care professionals will begin to accept how our thoughts greatly influence how we feel.

By Scott Bateman (not verified) on 10 Feb 2009 #permalink

I spent 8 YEARS being told that all My pain, problems, were PSYCHOLOGICAL. I *begged* the whole time for the doctors in Toronto to simply x-ray my neck, upper back, left shoulder. I had MANY 8severe* falls, head injuries. 8 blasted YEARS of pain, and thinking and being TOLD I was a *different* kind of mentally ill than my NORM-self. IDIOTS. I found out only a few weeks ago that I have SEVERE deterioration of my cervical DISKS. Not in a couple vertebral areas, but EVERY disk. Plus, that they WERE likely started from my 2 car accidents, my falls as a CHILD. Oh, and my Left shoulder, which I broke not long ago, was probably IN *worse* pain from the OLD injuries than breaking the BALL off the Humerus. And all lit took was a couple x-rays, and BAM, plain as daylight, I was no longer insane, I was BADLY MISDIAGNOSED. To the point the lack of belief & help made me suicidal, NOT the PAIN. Ridiculous in modern times, folks.

By Christopher Hudson (not verified) on 11 Mar 2009 #permalink

Oh. I also had a brain hemmorage removed about 5 years ago. The doctors told my parents that the huge clot that burst was ALSO from my OLD head injuries. my headaches, the constant ones NOT caused by my NECK, are actually from Optic NERVE pressure & DAMAGE. I have lost SIGNIFICANT portions OF my eyesight!. I have lost a HUGE amount fortunately ONLY of my Peripheral Vision. Blasted amazing lack of rational, logical treatment to tell me it was psychologically based pain, plain and simple.

By Christopher Hudson (not verified) on 11 Mar 2009 #permalink

I took cheap carisoprodal for years for my bad back and it did not work ,the only thing that worked was yoga.Good story

I had lower back, upper back and neck pain for years. After becoming clear on various psychological issues, the pain went away. Physical treatments didn't accomplish anything for me. I don't believe the pinched nerve theory adds up. Just as you can't turn on a light by pressing on the wire that connects it to a power source (you have to turn the switch), a neuron isn't activated by having something such as a disc press against its axon. Some sort of stimulus needs to be provided at the neuron's dendrites. Nociceptors are the only kind of neurons that take part in the creation of pain. The dendrites of a nociceptor aren't located by a person's spinal chord or the gaps that exist between two vertebra. A nociceptor's dendrites are located by the part of a person's body it is supposed to receive signals from, such as the tip of a person's finger.

The good news is that, while we can't realign our spines or fix our ruptured discs, we can control our perception of chronic pain. With the proper training, we can alleviate our own suffering.

Yes i do agree with this. Also to be honest chiropractors do really help. Specially when the pain is unbearable.

I have had a ''Pranamat'' for about 2 months. I have found a routine that I really like it. In the morning I lie on my mat without clothes. It hurts a little at first, but after a few minutes I feel a pleasant feeling and relaxation. Before I fall asleep I roll up the Prana Mat and place it on the floor. I fall asleep quickly. Nowadays I have a deeper more restful sleep since I started using my mat, and I feel more rested in the morning. When I wake up I sit on the end of the bed and place my feet on the mat and carefully allow my whole body weigh down on the points on the mat. It hurts more than lying with my back on it, but I have gotten used to this way too. I then stretch my arms up above my head, clasp my hands with the index fingers pointing up and do some Fire breathing for a few minutes while tracing the flow of energy from my soles up through the body and out through the index fingers. Refreshes me quickly and afterwards I notice how mindfully aware my soles have become. The feeling of obvious groundedness normally lasts for several hours.

I agree with Dr. Tom. Yoga does help a lot in relieving back pains. I read recently that Prolotherapy is also an effective treatment. I just don't know if there are any side effects about it.

Hi all.

Thank you, Jonah, for writing such an excellent article.

For those who are interested in learning more about TMS, there is a tremendous amount of information available at . It's completely nonprofit and is written by people like myself who have found Dr. Sarno's ideas extremely helpful in managing their pain.

Interesting points about how body and mind are connected. There are a lot of ailments that can be reduced by focusing on your mentality of the situation. I am really thankful that I came across this article. It reminds me of a segment on a talk show I had seen a while back about a girl who was born without pain receptors in her brain and by the time she was a toddler she had a problem with biting her nails. The fact that she couldn't feel pain actually caused a lot of harm to her body because she would gnaw away at her fingers unknowingly while biting her nails. I'm going to look deeper into what Dr. Sarno has written now, I find it very intriguing.

Very interesting article. I am researching some mental anxieties right now and am finding more and more everyday on how the mind and the body are connected. Most of the anxieties that I am learning about have to do with the mentality of the patient who suffers from it. I had no idea that someone could use mind over matter to get rid of physical pain. I will have to read up a bit more on Dr. Sarno's works.

Thanks for posting this!

To post numbers 16 and 17.. I have mild back pain that was brought on by a car accident some years back. I do yoga regularly and it really does help with the pain. I feel more flexible and it does wonders for my focus and mental psych. I will have to look into that wiki as I am very interested in learning more on this topic. Great article by the way!

Albert, that is probably one of the best ways I have heard the description of pain and the "pinched nerve" theory put. Also, I notice that when I am going through very stressful times in my life, I have (or notice) more pain from my arthritis. This can't just be a coincidence and this article was really helpful for shedding a little more light on a viewpoint of pain I had never really thought about before.

Rattling pleased with this amazing health and forethought information, I love your diets, I will update you on my condition.

My lumbar pain is really so long now, and i have checked various solutions, but until now i've not healed my lower back pain, i also attempted several lower back pain exercises, however they failed to work on me. Can your information really help back pain relief, can you offer me a reply quickly, i wait your reply, many thanks.

Im 14 and am a vancouverite. I am and always will be a? Canucks fan but these videos show me how much history there is to hockey. Total respect to all die the hard fans.

Also, since the movie discussed impacts of Enron on financial markets as well as trade markets, why not include information regarding impact of OPECs petroleum policies and pricing controls on our financial markets. I would be interested in learning more about OPECs role in controlling our economy.

I KNOW my back pain is somatised from childhood abuse as a victim of the bullies from age 6-11 and the silence I was taught to keep by everyone involved, parent, teacher, peers. Now 54, I have arthritis as well as "mechanical" problems (Royal National Orthopaedic Hospital) in hips and back, fingers and ankles. I have spent over £100,000 on therapy: osteopaths, naturopaths, PTSD therapy, Eye Movement Desensitisation (EMDR) counselling, CBT, Transactional Analysis, Gestalt, Psychodynamics, Group work, a tens machine etc, physio, pilates, yoga, imaginal healing, homeopathy, autogenics, opiate pain killers. I've used an osteopath for more than half my life and was first sent to a shrink aged 14. That's a pretty comprehensive range of therapies and 48 years experience of pain!

Believe me, there is a direct connection between physical and emotional pain. Now, when something/one stresses me, immediately pain lances up my back and the muscles start to tighten, my breathing changes and my fight/flight/freeze mechanism kicks in.

I also get nerve inflammation from endless outbreaks of one of the Shingles viruses around the lumbar spine at L3 L4 L5 S1, triggered by fear, pain, stress.

I have been that hopeless trapped person. I know from excruciating experience the second emotional pathway to pain, intimately. But I still do not give in to that despair: what doesn't break you makes you stronger. Hopelessness results in physical death if you live with it for long enough.

I take tricylics too. I am not "crazy", "merely" damaged. I still work as an artist and for an organisation part time in an undemanding role.

I await the roll out of d-cycloserine (sold as Seromycin) in the UK with that precious commodity, hope. If it's on Wikipedia it can't be too far away! ( Recent research suggests that D-cycloserine (d-4-amino-3-isoxazolidinone) may be effective in treating chronic pain.)

This is a great bag, thanks for the video!

By Bulah Groat (not verified) on 26 Aug 2011 #permalink

Virtually the exact same image is shown coming from a fairly wide variety of different angles and distances, indicating the vastness of the plains and the power that these characters hold (or will hold) them over.

The City Council reduced the tax rate in a time of emergency as the Manager optimized the Citys efficiency. That job has come to an end, with the exception of a second look at the Community Development Dept and outsourcing the lawn maintenance I dont see that the Manager has much more optimizing to do. The large reduction in the tax rate is not sustainable and its time to bring the rate back into line with the needs of the City. This position seemed to infuriate Jo whose comments were removed. Jo implied that all we, (those outside the Wall) wanted was to live off those inside the Wall. The comment was written with no spaces after the periods or commas, which can be identified easily enough if the rest of their comments are still on this board. The writing style was familiar to most who have been around for a while.

A fair pointI think itll be different. But I dont necessarily think that different is bad. For example, watch the first season of The Office. Its about 6 episodes. Its very different than the second season (they sorted some things out after getting viewer feedback). I think both Darryl and the skinny Sabre guy would make pretty hilarious bosses, and last weeks episode hinted at both of them getting a chance. Well see. I trust the writers.


Inside a way, It may be a very good point that he was elected, as he is already discredtitng the DemoRATS, and started a Conservative revolution. I wasn't a lot for politics 3 a long time ago, and have recently turn into really active. There's a Tax Day Tea Party about 3 miles from my residence that I is going to be attending. I also are going to be posting some videos around the liberal stomping grounds on Youtube genuine soon.